GW1--03517_Well Construction - GW1_20240612

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Taylor Ray Boger 4.WATER ZONES
FROM 'TO DI:N(RIrl'ION
Well Contractor Name ft. ft.
4614-A ft. ft.
NC W`ell Contractor Certification Number 15.OUTER CASING(for utulti-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 55 rt. 6.25 in, #21 J PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
OSS-2023-1211 FROM DIAMFTEN THICKNESS MATERIAL _
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROnt TO DI-%MFIET( SLOT SIZE THU KNESS M%TERI:\I.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft ft. in.
( 8) g PP Y) PPY( g
❑industrialiCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM "r0 MATERIAL EMILA(.ENIFNT METHOD A AMOUNT
❑irrigation 0 ft. 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Mtmitoring ❑Recovery ft. ft Cap Top with Bentonite Chips
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable
FROM TO MATERIAI FNIPI.A('EM ENT MEaIIOD..
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage D ft.
❑Experimental Technology ❑Subsidence Control --
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.)
❑Geothermal(Ileating/Cooling Return) ['Other(explain under#21 Remarks) 0 rt. 55 ft. OVER BURDEN
5-23-2024 55 ft• 265 ft• GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft. _ _ _
5a.Well Location: ft. ft, 8 l C L,L''V E D
CMH HOMES INC ft. rt. A. 1
Facility%Owner Natne Facility lD#(if applicable) J U N 2 2024
ft. ft.
128 ALBERTO WAY ST PAUL SUB LOT 9 HENDERSONVILLE
ft. ft. Itlorn,.car, 3',.� r Litti
Physical Address.City.Alai lip 21.REMARKS Dtt�'dt "''4
HENDERSON 0602612745 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W � t 6-4-2024
Signature of ed ell ntractor Date
6.Is(are)the well(s): laPermanent or ❑Temporary By signing this form,1 hereby certify that the unll(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
1/this is a repair.fill out knows:well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supple wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@ 100') construction to the following:
10.Static water level below top of casing 50 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•_ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: in addition to sending the fonn to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)4 Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 25 well construction to the county health department of the county where
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013